Burnout in International Medical Graduate Trainees in the United Kingdom Compared to Domestic Medical Graduate Trainees. Analysis of Data from the GMC's National Training Survey in 2019 and 2021.

Introduction: International Medical Graduates (IMGs) have lower educational attainment and a higher rate of complaints against them compared to Domestic Medical Graduates (DMG). The aim of this study was to investigate the potential role of burnout on these adverse outcomes experienced by IMGs. Methods: Every year, the General Medical Council (GMC) conducts the National Training Survey of all doctors in the United Kingdom which includes optional questions on work-related burnout from the Copenhagen Burnout Inventory (CBI). Work-related burnout data for doctors in training, linked to country of Primary Medical Qualification were obtained from the GMC for the years 2019 and 2021. Burnout scores of IMGs and DMGs were compared using Chi2. Results: The total number of eligible participants in 2019 and 2021 was 56,397 and 61,313 respectively. The response rates for all doctors in training to the CBI were 35,739 (63.4%) in 2019, and 28,310 (46.2%) in 2021. IMGs were at a lower risk of burnout compared to DMGs, 2,343 (42.9%) vs 15,497 (51.2%), Odds Ratio (OR) 0.72 (CI 0.68-0.76, P < 0.001) in 2019; and 2,774 (50.2%) vs 13,000 (57.1%), OR 0.76 (CI 0.71-0.80, P < 0.001) in 2021. Discussion: IMGs, as a group, appear to be at a lower risk of work-related burnout compared to DMGs. Burnout is unlikely to be contributing to lower educational attainment and higher rates of complaints experienced by IMGs compared to DMGs.

Linguistic coaching: a pilot study of one-to-one near-peer coaching for international GP trainees in Yorkshire.

INTRODUCTION: International medical graduates (IMGs) have a higher rate of examination failure and are more likely to be referred to the regulator for professional performance issues than their UK-trained counterparts. Support for IMGs to reduce differential attainment takes many forms. A pilot study to assess the feasibility and utility of early intervention to increase the support available for IMGs entering general practice (GP) training was undertaken. METHOD: IMGs entering GP training in one UK region were offered one-to-one, near-peer linguistic coaching during their first two weeks of training. A session focusing on cultural acclimatisation, local accent and dialect using mock patient consultations was delivered and evaluated. RESULTS: The coaching was valued by the trainees and the intervention allowed very early identification of a trainee who needed further support. It was possible to identify such trainees using a non-medical volunteer student coach. DISCUSSION: Use of a non-medical, near-peer coach for one-to-one linguistic support has not previously been described for IMGs. This pilot study confirms the acceptability and utility of this approach. Early identification of trainees requiring enhanced support allows targeted interventions in a time-pressured speciality training programme. Further study with a larger-scale and longer-term coaching programme, assessing trainee feedback and uptake of early supportive intervention is recommended.

Indian medical graduates in New Zealand: does anyone win?

Medical migration has become a global phenomenon, partly led by easier air travel, economic factors and the expansion of medical technology. New Zealand has gradually evolved from being 'bicultural' to a multicultural, multitextured society. The movement of the Indian people, particularly Indian physicians, will be the focus of this paper. In the last three decades, migration eligibility in New Zealand has changed from countries of origin or ability to speak English, to profession and skills. Despite struggling with its own issues, New Zealand has proven to be a preferred destination for Indian medical graduates (IMGs). India is widely recognised as the largest 'donor country' for doctors, many of whom go on to establish themselves as leaders and prominent figures in their field. This migration involves three parties: India as a donor country, New Zealand as a recipient country and IMGs as the drivers of this process. Factors behind this growing phenomenon are examined and recommendations are made so that all three parties can benefit from it.

International Medical Graduates in Nephrology: A Guide for Trainees and Programs.

A significant portion of the nephrology workforce has traditionally consisted of non-United States (US) citizen international medical graduates and international research trainees. Although international medical graduates are offered opportunities for training and professional growth that are beyond those available in their countries of origin, they typically encounter barriers to transition from training to practice and early-stage career development. In this article, we describe the exchange visitor and temporary worker visas granted to foreign trainees in the United States, focusing on the transition from training to nephrology practice and/or research. While we provide general recommendations on how to navigate this tedious and unpredictable process for both programs and trainees, consultation with immigration attorneys is indispensable for a successful outcome. Trainees are therefore encouraged to seek continuous support from their programs/sponsors and assistance from immigration representatives at their training institutions. We provide a positive message to emphasize that there are many pathways to arrive at the desired post-training destination.

Egalitarianism in surgical training: let equity prevail.

This study aimed to quantify core surgical trainee (CST) differential attainment (DA) related to three cohorts; white UK graduate (White UKG) versus black and minority ethnic UKG (BME UKG) versus international medical graduates (IMGs). The primary outcome measures were annual review of competence progression (ARCP) outcome, intercollegiate Membership of the Royal College of Surgeons (iMRCS) examination pass and national training number (NTN) selection. Intercollegiate Surgical Curriculum Programme (ISCP) portfolios of 264 consecutive CSTs (2010-2017, 168 white UKG, 66 BME UKG, 30 IMG) from a single UK regional post graduate medical region (Wales) were examined. Data collected prospectively over an 8-year time period was analysed retrospectively. ARCP outcomes were similar irrespective of ethnicity or nationality (ARCP outcome 1, white UKG 60.7% vs BME UKG 62.1% vs IMG 53.3%, p=0.395). iMRCS pass rates for white UKG vs BME UKG vs IMG were 71.4% vs 71.2% vs 50.0% (p=0.042), respectively. NTN success rates for white UKG vs BME UKG vs IMG were 36.9% vs 36.4% vs 6.7% (p=0.023), respectively. On multivariable analysis, operative experience (OR 1.002, 95% CI 1.001 to 1.004, p=0.004), bootcamp attendance (OR 2.615, 95% CI 1.403 to 4.871, p=0.002), and UKG (OR 7.081, 95% CI 1.556 to 32.230, p=0.011), were associated with NTN appointment. Although outcomes related to BME DA were equitable, important DA variation was apparent among IMGs, with iMRCS pass 21.4% lower and NTN success sixfold less likely than UKG. Targeted counter measures are required to let equity prevail in UK CST programmes.

Identifying the Geographic Profile of International Visitors to the United States for Neurosurgical Education: A Single Institution's Experience.

BACKGROUND: Departments of neurosurgery in the United States have had a long history of hosting international visitors for the advancement of their neurosurgical education. The goal of the present study was to determine the existence of a geographic profile of international visitors for education purposes, both students and graduates, to the United States through the anecdotal experience of 1 department to explore the reach and worth of hosting such opportunities. METHODS: Administrative records were retrospectively reviewed for international visitors over the preceding 10 years, 2009-2019, were surveyed at 1 institution. Visitors were grouped as either medical students or graduates, visiting for clinical or research purposes. Geographic trends were compared using the Pearson chi-squared test. RESULTS: We identified 128 visitors from 33 countries during the study period. The most common home countries were Italy (10%), China (9%), and India (7%). The cohort involved 62 (48%) students and 66 (52%) graduates, and 59 (46%) and 69 (54%) visited for clinical and research purposes, respectively. The geographic distribution of student versus graduate visitors was statistically significant by region (P < 0.01). However, the geographic distribution of clinical versus research visitors was not statistically different by region (P = 0.62). CONCLUSIONS: There appears to be international appeal worldwide to participate in neurosurgical education in the United States. At our institution, every geographic region was represented in our most recent decade of experience. International visitor profiles appear to be associated with particular geographic patterns depending on their status as either a medical student or graduate.

Evaluation of the reflecting team as an educational intervention.

Background: The reflecting team is a way of exploring clinical or educational dilemmas. A key difference from traditional case discussion is that the case presenter is not actively involved in the group discussion but instead listens to the ideas and thoughts generated, without contributing to the narrative. The origins of the reflecting team are in family therapy and there is little evidence on how successfully the technique can be transposed to clinical or educational practice.Aim: To evaluate the effectiveness of the reflecting team as an educational intervention.Design and setting: Interpretive action research involving 10 GPs who were either enrolled on the Induction and Refresher Scheme or who were members of a learning set of GP educators.Method: Interview data were audio-recorded, transcribed verbatim and thematic analysis was used to identify themes.Results: The reflecting team appeared to be an effective and acceptable intervention. Key features of the reflecting team included the opening up of new perspectives, feeling validated by peers, the need for ground rules and the perception of the reflecting team as a practical tool.Conclusions: The reflecting team is a new way of undertaking case discussion in GP education and seems to offer some advantages over traditional case discussion. It lends itself well to learning groups and it is possible that the idea might be transposed to clinical settings too.

Exploring reasons for differences in performance between UK and international medical graduates in the Membership of the Royal College of General Practitioners Applied Knowledge Test: a cognitive interview study.

OBJECTIVES: International medical graduates (IMGs) perform less well in national postgraduate licensing examinations compared with UK graduates, even in computer-marked multiple-choice licensing examinations. We aimed to investigate thought processes of candidates answering multiple- choice questions, considering possible reasons for differential attainment between IMGs and UK graduates. DESIGN: We employed a semistructured qualitative design using cognitive interviews. Systematic grounded theory was used to analyse data from 'think aloud' interviews of general practitioner specialty trainees (GPSTs) while answering up to 15 live questions from the UK Membership of the Royal College of General Practitioners Applied Knowledge Test (AKT). SETTING: East Midlands, UK. PARTICIPANTS: 21 GPSTs including 13IMGs and 8 UK-trained doctors. OUTCOMES: Perceptions of participants on how they answered AKT questions together with strategies used or difficulties experienced. RESULTS: We interviewed 21 GPSTs (8 female, 13 male, 13 IMGs, 14 from black and minority ethnic groups, age 24-64 years) in years 1-3 of training between January and April 2017. Four themes were identified. 'Theoretical versus real-life clinical experience': participants reported difficulties recalling information and responding to questions from theoretical learning compared with clinical exposure; rote learning helped some IMGs recall rare disease patterns. Recency, frequency, opportunity and relevance: participants reported greater difficulty answering questions not recently studied, less frequently encountered or perceived as less relevant. Competence versus insight: some participants were over optimistic about their performance despite answering incorrectly. Cultural barriers: for IMGs included differences in undergraduate experience, lack of familiarity with UK guidelines and language barriers which overlapped with the other themes. CONCLUSIONS: The difficulties we identified in candidates when answering AKT questions may be addressed through training. IMGs face additional difficulties which impede examination success due to differences in educational experience, content familiarity and language, which are also potentially amenable to additional training support.

Trauma electives in South Africa provide valuable training for international surgeons.

BACKGROUND: Trauma electives in South Africa (SA) are common and many foreign-based surgeons have undertaken such electives over the past 3 decades. Despite this, little academic attention has been paid to these electives, which remain largely informal and unstructured. This project aims to redress this deficit. OBJECTIVES: To investigate and document the extent of trauma clinical electives and to assess their impact on the careers of foreign surgeons who have undertaken such electives. METHODS: A mixed methods-style questionnaire was compiled, which sought to document the demographics of surgeons undertaking an SA trauma clinical elective, the trauma clinical experience they had prior to the elective, as well as the volume of experience they acquired during the elective. RESULTS: Sixty questionnaires were sent out and 21 were completed. There were 16 male and 5 female respondents. Only 17 had undertaken a formal trauma rotation before their elective in SA. The mean number of major resuscitations managed prior to rotating through surgery departments in SA was 15, and the mean number managed during a 12-month rotation in SA was 204. It would take each respondent 14 years in their country of origin to acquire an equivalent level of exposure to major resuscitation. During the year before their elective, each surgeon had been exposed to a mean number of the following: 0.5 gunshot wounds (GSWs), 2 stab wounds (SWs), 0.1 blast injuries and 19 road traffic accidents (RTAs). The equivalent mean number for their year in SA was 106 GSWs, 153 SWs, 4 blast injuries and 123 RTAs. The time necessary to achieve a similar level of exposure to their SA experience if they had remained in their country of origin was 213 years for GSWs, 73 years for SWs, 41 years for blast injuries and 7 years for RTAs. Compared with their SA elective, it would take each respondent 3 years to insert as many central venous lines, 9 years to perform the same number of tube thoracostomies, 9 years to manage as many surgical airways, 18 years to explore as many SWs of the neck and 93 years to explore as many GSWs of the neck. Furthermore, it would take 33 years to see and perform as many laparotomies for SWs to the abdomen, 374 years to perform an equivalent number of GSWs to the abdomen and 34 years of experience to perform as many damage-control laparotomies in their countries of origin. In terms of vascular trauma, it would take 23 years to see as many vascular injuries secondary to SWs and 77 years to see an equivalent number of vascular injuries secondary to GSWs. CONCLUSIONS: A trauma clinical elective in SA provides an unparalleled exposure to almost all forms of trauma in conjunction with a well-developed academic support programme. Formalising these trauma electives might allow for the development of exchange programmes for SA trainees who wish to acquire international exposure to advanced general surgical training.

A description and evaluation of an educational programme for North West England GP trainees who have multiple fails in the Clinical Skills Assessment (CSA).

Background and aims: Trainees who have failed the Clinical Skills Assessment (CSA) component of the Membership of the Royal College of General Practitioners (MRCGP) licensing examination present an educational challenge. This study describes a CSA resit programme and evaluates the outcomes when doctors reattempt the CSA. Methods: We delivered an educational programme to trainees in North West England who were resitting the CSA in 2016 and 2017: the majority were undertaking periods of additional training time. After the programme, we compared their CSA pass rates with national pass rates. Results were stratified by the number of previous attempts and source of primary medical qualification. Results: The trainees who took part in this programme had pass rates that exceeded national pass rates. Results were particularly encouraging for the group of International Medical Graduates (IMGs) who had previously failed the CSA two or more times. Conclusions: We suggest several possible explanations for these results. All trainees reappraised their learning needs, using educational tools written by CSA assessors. The programme was delivered by experienced, trained educators working with both trainee and trainer in order to produce shared educational plans. The training community's commitment to support trainees improved their confidence and motivation.

Enhancing health professional education capacity in the Western Pacific region.

In the past 5 years there has been a rapid rise in numbers of foreign-trained medical graduates returning to their countries to work as interns across the Western Pacific. These graduates were found to have a varied and different level of clinical knowledge and skill from that previously experienced in the region. This change in workforce profile led to an urgent need for upskilling clinicians as educators and supervisors. A team of clinical education facilitators were invited to design and deliver context-specific professional education workshops to address this need. These workshops were designed to equip clinical staff with education and supervision skills to optimise teaching and learning opportunities in clinical settings for these new graduates of foreign medical programs. Embracing a collaborative approach and addressing learning needs in local contexts has enabled the team to enhance medical education capacity in the Western Pacific region. This article presents the context of the need for and development of clinical education workshops for intern supervisors in the Western Pacific.

A Pilot Study Examining Factors Influencing Readiness to Progress to Indirect Supervision Among First Year Residents in a General Psychiatry Training Program.

OBJECTIVE: In the first year of training, psychiatry residents progress from direct supervision to indirect supervision but factors predicting time to transition between these levels of supervision are unknown. This study aimed to examine times for transition to indirect levels of supervision and to identify resident factors associated with slower progression. METHODS: The authors compiled data from training files from years 2011-2015, including licensing exam scores, age, gender, medical school, month of first inpatient psychiatry rotation, and transition times between levels of supervision. Correlational analysis examined the relationship between these factors. Univariate analysis further examined the relationship between medical school training and transition times between supervision levels. RESULTS: Among the factors studied, only international medical school training was positively correlated with time to transition to indirect supervision and between levels of indirect supervision. CONCLUSIONS: International medical graduate (IMG) interns in psychiatry training may benefit from additional training and support to reach competencies required for the transition to indirect supervision.

Formação em medicina no Brasil: cenários de prática, graduação, residência médica, especialização e revalidação de diplomas. Textos relativos ao conteúdo apresentado no VIII Fórum de Ensino Médico, Brasília, 5 e 6 de setembro de 2017 / Medical training in Brazil: practice scenarios, graduation, medical residency, specialization and revalidation of diplomas. Texts related to the content presented in the VIII Medical Education Forum, Brasilia, September 5th and 6th, 2017

Este livro ­ Formação em medicina no Brasil: cenários de prática, graduação, residência médica, especialização e revalidação de diplomas ­ é o segundo número da série Cadernos de Educação Médica, produzida pelo Conselho Federal de Medicina (CFM) com a participação direta dos membros da Comissão que se dedica à análise do tema nesta Autarquia. Com periodicidade anual, desta vez esta publicação traz textos produzidos a partir dos debates realizados durante o VIII Fórum da sua Comissão de Ensino Médico, que ocorreu em Brasília (DF), nos dias 5 e 6 de setembro de 2017. Em síntese, são três os eixos que compõem este volume. Inicialmente é abordado o problema da proliferação indiscriminada de escolas médicas no Brasil, com suas consequentes inquietações relacionadas aos precários cenários de prática disponíveis no Sistema Único de Saúde. Nesse sentido, também há pertinentes reflexões sobre as preocupações oriundas da criação da Empresa Brasileira de Serviços Hospitalares (Ebserh) e as expectativas geradas pela implementação do Sistema de Acreditação de Escolas Médicas (Saeme), resultado de parceria entre o CFM e a Associação Brasileira de Educação Médica (Abem). O segundo ponto discutido neste volume se refere aos cursos de especialização e a residência médica (RM), a qual é vista como o padrão ideal para a formação do especialista em medicina. Ressalte-se a existência de definição legal de que o acesso a esse título só pode ser obtido por dois caminhos: a formação em um programa de RM ou a aprovação em concurso de título realizado por sociedades de especialidades médicas reconhecidas pela Comissão Mista de Especialidades.

A Comparison of Objective Assessment Data for the United States and International Medical Graduates in a General Surgery Residency.

OBJECTIVE: To compare objective assessment scores between international medical graduates (IMGs) and United States Medical Graduates. Scores of residents who completed a preliminary year, who later matched into a categorical position, were compared to those who matched directly into a categorical position at the Mayo Clinic, Rochester. DESIGN: Postgraduate year (PGY) 1 to 5 residents participate in a biannual multistation, OSCE-style assessment event as part of our surgical training program. Assessment data were, retrospectively, reviewed and analyzed from 2008 to 2016 for PGY-1 and from 2013 to 2016 for PGY 2 to 5 categorical residents. SETTING: Academic medical center. PARTICIPANTS: Categorical PGY 1 to 5 General Surgery (GS) residents at Mayo Clinic Rochester, MN. RESULTS: A total of 86 GS residents were identified. Twenty-one residents (1 United States Medical Graduates [USMG] and 20 IMGs) completed a preliminary GS year, before matching into a categorical position and 68 (58 USMGs and 10 IMGs) residents, who matched directly into a categorical position, were compared. Mean scores (%) for the summer and winter multistation assessments were higher for PGY-1 trainees with a preliminary year than those without (summer: 59 vs. 37, p < 0.001; winter: 69 vs. 61, p = 0.05). Summer and winter PGY-2 scores followed the same pattern (74 vs. 64, p < 0.01; 85 vs. 71, p < 0.01). For the PGY 3 to 5 assessments, differences in scores between these groups were not observed. IMGs and USMGs scored equivalently on all assessments. Overall, junior residents showed greater score improvement between tests than their senior colleagues (mean score increase: PGY 1-2 = 18 vs. PGY 3-5 = 3, p < 0.001). CONCLUSIONS: Residents with a previous preliminary GS year at our institution scored higher on initial assessments compared to trainees with no prior GS training at our institution. The scoring advantage of an added preliminary year decreased as trainees progressed through residency.

Dealing with foreign cultural paradigms: A systematic review on intercultural challenges of international medical graduates.

OBJECTIVES: An increasing number of International Medical Graduates (IMG), who are defined to be physicians working in a country other than their country of origin and training, immigrate to Western countries. In order to ensure safe and high-quality patient care, they have to take medical and language tests. This systematic review aims to (1) collect all empiric research on intercultural communication of IMGs in medical settings, (2) identify and categorize all text passages mentioning intercultural issues in the included studies, and (3) describe the most commonly reported intercultural areas of communication of IMGs. METHODS: This review was based on the PRISMA-Guidelines for systematic reviews. We conducted a broad and systematic electronic literature search for empiric research in the following databases: MEDLINE, BIOSIS Citation Index, BIOSIS Previews, KCI-Korean Journal Database and SciELO Citation Index. The search results were synthesized and analyzed with the aid of coding systems. These coding systems were based on textual analysis and derived from the themes and topics of the results and discussion sections from the included studies. A quality assessment was performed, comparing the studies with their corresponding checklist (COREQ or STROBE). Textual results of the studies were extracted and categorized. RESULTS: Among 10,630 search results, 47 studies were identified for analysis. 31 studies were qualitative, 12 quantitative and 4 studies used mixed methods. The quality assessment revealed a low level of quality of the studies in general. The following intercultural problems were identified: IMGs were not familiar with shared decision-making and lower hierarchies in the health care system in general. They had difficulties with patient-centered care, the subtleties of the foreign language and with the organizational structures of the new health care system. In addition, they described the medical education in their home countries as science-oriented, without focusing on psychosocial aspects. CONCLUSION: There is a need for a better training of IMGs on culture-related and not culture-related topics in the new workplace country. The topics that emerged in this review constitute a basis for developing these courses. Further empiric research is needed to describe the findings of this review more precisely and should be in accordance with the existing reporting guidelines.